NC Urban and Community Forestry Grant Program

REQUEST FOR REIMBURSEMENT

Grant Number UCF-17- Contract #

Reimbursement for period through

______
Grantee Name
______
Federal Tax ID Number (FEIN)
______
Street or PO Box Number
______
City / State / Zip
______
Attention: (Person/Department to receive payment) /

PART II

Complete the Following if Requesting Final Reimbursement

Date Project Completed ______

Total Project Cost (include current and previous amounts)

A. Federal Share (Total Reimbursements) $______
B. Grantee Share (Total Cash Match) $ ______
C. Grantee Share (Total In-Kind Match) $ ______
D. Total Match (B+C) $ ______
(must equal or exceed Total Reimbursements)
E. Total Project Cost (A+D) $______

PART I

Reimbursements Requested Today

A. Federal Funds Requested for
Reimbursement (This Period) $______

Non-Federal Match (This Period)

B. Cash Match this Period $______
C. In-Kind Match this Period $______
Total Match this Period (B+C) $______
(must equal or exceed reimbursement request amount)
Reimbursement Request minus 20%
holdback (until project completed) $______/

For NCFS Official Use Only

Payment Approved by: ______
Amount: $______
□ 20% holdback included
in final payment
Date: ______

Grantee Certification: I certify that this request for reimbursement of funds is in accordance with the terms and conditions of the North Carolina Urban and Community Forestry Grant Program and the rules and regulations set forth by the USDA Forest Service and the United States Office of Management and Budget. I also certify that matching requirements have been met and sufficient documentation exists in our files and are available upon request or in the event of an audit. I also certify that all data and accomplishments reported are correct.

______

Print Name of Authorized Representative

______

Title of Authorized Representative

______

Signature of Authorized Representative (sign with BLUE ink)

______

Date

Instructions

1.  Attach Expense and Match Documentation Form (and Manpower and Equipment Documentation if needed).

2.  Attach copies of documentation for grant expenses: receipts, paid invoices, payroll records, etc. for grant expenses and for match items. Number each receipt item and itemize on the form

3.  If requesting final reimbursement, complete Parts I & II of this form, otherwise only complete Part I.

4.  If requesting final reimbursement, include the Final Accomplishment Report, Accomplishment Narrative, and other required documentation.

5.  Keep a copy of everything submitted.

6.  All project records, including financial records, must be maintained for 5 years beyond project completion.